State investigation reports show that the patient-care record at the San Diego Hospice was not spotless in the months before it faced financial problems prompted by a Medicare audit.

In 2011 and 2012, the California Department of Public Health cited the hospice for lapses in care that resulted in at least four narcotic-related overdoses and, in one case, neglect that resulted in gruesome sores. For a time, the organization’s participation in Medicare was threatened.

Kathleen Pacurar, the hospice’s chief executive, said Tuesday that she stands by her previous statements that the care San Diego Hospice has provided since the 1970s has been excellent. She said the incidents cited in the government reports, while regrettable, represent only a sliver of the patients treated by the hospice.

“The number of challenging incidents were very rare, and that’s why I always felt very comfortable saying this was not a quality issue,” Pacurar said. “These were issues that we self-reported because we also hold ourselves to a high standard.”

San Diego Hospice has since declared bankruptcy, saying it fears it may have to return as much as $60 million to Medicare as the result of an ongoing audit into its admissions practices.

The organization, once the dominant operator in the region and one of the largest in the nation, has transferred all but about 20 patients to other hospices, and bankruptcy court is moving toward the sale of its Hillcrest property at auction on April 30.

Documents show that, at the same time the organization faced a Medicare audit, it also was undergoing scrutiny related to the care it provided.

A document filed on May 1, 2012, states that the hospice reported an adverse event on March 3, 2012, after a caregiver, who was not a San Diego Hospice employee, administered 20 times the prescribed dose of morphine to a 91-year-old patient who died “approximately one hour following the orally administered dose.”

The report states that the female patient had been “unable to take food/fluids for several days.” Her death, the report states, was judged to be “imminent” two days before the overdose occurred.

A doctor later said that her death was “unlikely due to morphine but due to underlying terminal illness,” according to the report.

After investigating the death, the U.S. Department of Health and Human Services concluded that medication kits dispensed to patients “did not have a system in place to ensure the safe administration of medications in the patients’ homes.”

The kits were distributed to 787 patients, who were notified not to use the kits until syringes were exchanged.

Pacurar said that the hospice issued about 10,000 of the medication kits, and only had one problem.

“We had the situation under control within 72 hours,” she said.

Another patient died one day after another narcotic-related issue occurred on Aug. 7, 2011. That was when a medication pump delivered “five times more morphine sulfate than ordered by the physician” over a 20-hour period.

An investigation later found that the device was incorrectly programmed.

Hospice officials responded that they instituted a new policy, which included verification of orders by a second nurse, after investigators said the “facility failed to implement immediate corrective actions” to prevent recurrence of the error.

After the hospice made changes in how it trains its employees and handles the pumps, the federal health department accepted its corrective actions.

The same report that outlined the medication pump problem also found fault with the hospice’s failure to report, and properly care for, a patient with Parkinson’s disease admitted on Jan. 26, 2011, who “had a large, split-open, draining wound on the scrotum, bruising on the tailbone and buttocks with developing pressure sores, a blood soaked brief and a blood stained bed.”

Two nurses were fired as a result of the poor care, according to the report.

An initial threat of suspending the organization’s Medicare participation never materialized.

Barbara Miltenberger, a Missouri-based attorney who specializes in these types of cases, said it is common for regulators to threaten an organization’s Medicare participation during the investigation process. But she said that threat is seldom acted upon.

“I would say the majority of times they do not lose their certification,” Miltenberger said.